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DESCRIPTIONThe goals of preventive health services are to avoid the development of disease and to diagnose disease in its early stages before it results in significant morbidity. Created in 1984, the U.S. Preventive Services Task Force (USPSTF or Task Force) is an independent group of national experts in prevention and evidence-based medicine. The Task Force works to improve the health of all Americans by making evidence-based recommendations about clinical preventive services such as:
The Guide to Clinical Preventive Services is available to those who seek to ensure that their patients receive the highest quality clinical preventive services. It is an evidence-based tool to be used at the point of patient care. Findings and recommendations from the USPSTF guide are routinely used in a variety of settings to improve the preventive care that patients receive. As more information becomes available to clinicians and patients alike, AHRQ's goal is to help improve patients' health and well being, and contribute to better health outcomes overall.
These recommendations apply only to people who have no signs or symptoms of the specific disease or condition that the screening, counseling, or preventive medication targets. Recommendations address only services offered in the primary care setting or services referred by a primary care clinician. The Task Force makes recommendations to help primary care clinicians and patients decide together whether a preventive service is right for a patient’s needs.
Since 1998, through acts of the U.S. Congress, the Agency for Healthcare Research and Quality (AHRQ) has been authorized to convene the Task Force and to provide ongoing scientific, administrative, and dissemination support to the Task Force.
The letter grade linked to each recommendation reflects the magnitude of net benefit and the strength and certainty of the evidence supporting the provision of a specific preventive service. These grades translate to practice guidance for clinicians:
POLICYMedically Necessary Screening
Only services/procedures (screenings, counseling services, and preventive medications) with "A" or "B" USPSTF recommendations are considered medically necessary under this policy. The following are considered medically necessary based on grade “A” or grade “B” by the USPSTF:
I. U.S. Preventive Services Task Force Adult "A" and "B" Recommendations
NOT MEDICALLY NECESSARY SCREENING
ALL other services/procedures performed for screening purposes are considered not medically necessary, including, but not limited to:
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
POLICY HISTORY12/01/2012: New policy added.
08/20/2013: Policy statement revised to add Calcium; total testing as not medically necessary for screening purposes.
07/23/2015: Code Reference section updated for ICD-10.
06/06/2016: Policy number L.2.01.410 added. Policy Guidelines updated to add medically necessary definition.
SOURCE(S)U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/recommendations.htm
American Academy of Family Physicians, Summary of Recommendations for Clinical Preventive Services, October 2012. http://www.aafp.org/online/etc/medialib/aafp_org/documents/clinical/CPS/rcps08-2005.Par.0001.File.tmp/SummaryOfRecommendationsForClinicalPreventiveServices.pdf
Five Things Physicians and Patients Should Question. http://choosingwisely.org/wp-content/uploads/2012/04/Five-Things.pdf. The following nine United States specialty societies representing 374,000 physicians developed lists of Five Things Physicians and Patients Should Question in recognition of the importance of physician and patient conversations to improve care and eliminate unnecessary tests and procedures:
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
Not Medically Necessary Codes
All procedure codes filed for screening purposes that are not listed as grade a “A” or grade “B” recommendation by the USPSTF in the "Policy" section above are considered not medically necessary and not eligible for coverage.
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